Nursing 質問

An unstable client with hyperglycemic hyperosmolar syndrome (HHS) has been assigned to the nurse. Which action should the nurse take initially?Insert a urinary catheter. Prepare to administer isotonic IV fluids. Evaluate the client's airway. Place two large bore IVs.

The nurse is teaching a female client who has had frequent urinary tract infections. Which statement by the client would indicate the need for additional teaching? "I need to urinate after having sexual intercourse." "I need to drink at least 2000ml of fluid a day." "I need to wipe my perineum from the back to front after using the toilet." "It is best to wash my hands before and after using the restroom."

The nurse is reviewing medication instructions with a client who is experiencing alopecia and is prescribed minoxidil (Rogaine). Which statement is true about the use of minoxidil for the treatment of alopecia? Treatment must continue to maintain new hair growth. Wash hair and scalp first and then apply while hair is still damp. Apply medication to different areas of the body for desired hair growth. The amount of the balding present will determine the dose applied.

A serum sample is obtained from a client who is being evaluated for crushing chest pain which radiates up to their jaw and down their left arm that started an hour ago. Which abnormal lab value would the nurse anticipate to be present indicating an acute coronary syndrome/myocardial infarction?Troponin. Myoglobulin. Creatine kinase-MB. High density lipoprotein.

client prescribed digoxin (Lanoxin) for atrial fibrillation calls the clinic's triage nurse reporting stomach pain and feeling weak from nausea and diarrhea. The client also reports drowsiness and confusion from a persistent headache for the past two days. Which action should the nurse take first? Inquire if anyone else in the household is experiencing the same symptoms. Ask the client about recent fluid intake and frequency of voiding and diarrhea. Check to see if the client had received yearly influenza and pneumonia vaccinations. Instruct the client to come to the clinic or urgent care to be seen by a healthcare provider.

A client, who had a laparoscopy cholecystectomy two days ago, calls the clinic's triage nurse in the morning, complaining that they have been awake all night feel feeling restless and anxious, like something isn't right with them and are afraid of dying. Which is the most appropriate nurse's response?Questioned the client, if they are experiencing epigastric pain when eating. Advise the client to return to the clinic now to be seen by their gastric surgeon. Explained to the client, it may be discomfort from the gas used during the procedure. Instruct the client to monitor their temperature every four hours and report if temp >100.5°F (37.8°C).

Client is prescribed angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) improve the function of their diagnosed heart failure. What should the nurse assess first prior to administering these medications to a client?Apical pulse. Heart sounds. Blood pressure. Intake and output.

Which treatment should the nurse plan to implement for a client diagnosed with septicemia?PO antibiotics and IV fluid resuscitation. IV antibiotics and IV fluids at a keep open rate. IV antibiotics and IV fluid resuscitation. PO antibiotics and IV fluids at a keep open rate.

An older adult client reports frequent dizzy spells. To assess for orthostatic hypotension, what action should the nurse take first?Assist client to a supine position. Position the client in a semi-Fowler's position. Ask the client to stand upright. Help the client sit on the side of the bed.

A 12-year-old client presents suddenly with signs of shock; weak and rapid pulse; bronchoconstriction and laryngeal edema. What should the nurse suspect is the cause of this presentation? Bronchial asthma. Anaphylaxis. Bronchiolitis. Respiratory distress syndrome.

A client who was diagnosed with a urinary tract infection and prescribed antibiotic two days ago has returned to the clinic complaining of fever and chills, accompanied with flank pain and nausea and vomiting. Which condition should the nurse suspect the client is experiencing? Cystitis. Pyelonephritis. Urothelial cancer. Acute kidney injury.

The nurse is working with the medical team to stabilize a client who is in shock. The nurse knows the physician will likely order a fluid challenge. Which action should the nurse take first?Establish two IV catheters. Begin warming IV fluids. Encourage the client to take fluids in orally. Obtain orthostatic blood pressures.

The family and friends of a client with a heroin addiction are planning an intervention meeting to convince the client to seek help. Which strategy should the group employ to help ensure a successful intervention? Make notes on what to say to the client and rehearse before the meeting. Attempt the intervention at a time when the client is under the influence. Stage the intervention in a public place that is familiar to the client. Set boundaries and be prepared to act in case the client behaves defensively.

The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). What expected patient outcome should the nurse include in the plan of care? The client will remain free of infection. The client will maintain cool, dry skin. The client will remain hypotensive. The client will return to baseline activity level by day 3.

The nurse is preparing discharge instructions for a client diagnosed with acute coronary syndrome. Which is an expected outcome when effective client education is provided?The client will verbalize lifestyle changes that are needed. The client will require additional teaching. The client will question the need to take hypertensive medications. The client will refuse to adhere to a cardiac diet.

A client with extracellular fluid volume deficit has received 500ml bolus of normal saline intravenously. Which finding from the nurse's assessment indicates that the fluid deficit is improving?Heart rate is100 beats/minute. Capillary refill less than 2 seconds. Skin tenting is present on the dorsum of the hand. Urine specific gravity of 1.030.

A client with a blunt chest trauma has developed a tension pneumothorax. Which piece of equipment should a nurse anticipate and obtain immediately for the healthcare provider to use to help assist the client with this condition?A chest tube. A large bore needle. An elastic bounding wrap. A non-permeable occlusive dressing.

The nurse is caring for a client who recently had a myocardial infarction. Which is the first action the nurse should take when a client begins exhibiting signs of cardiogenic shock?Prepare to administer ionotropic agents. Encourage the client to breath slowly. Place the client in prone position. Give the client aspirin.

The nurse is educating a pregnant client about breastfeeding. Which information should the nurse provide regarding effective breastfeeding of a healthy neonate?Breastfeeding should begin within the first hour of life. Breast milk should be supplemented with formula. Newborns should nurse every 2 to 3 hours. Pacifier should be used between feedings.

The nurse is assessing a newborn. The newborn appears pink with blue extremities, with arms and legs flexed. The nurse also notes that the child has a heart rate greater than 100 and is crying during the assessment. What APGAR score should the nurse assign? 4. 6. 7. 9.